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F0641
D

Inaccurate MDS Assessments for PASARR and Insulin Use

Rockledge, Florida Survey Completed on 04-03-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the Pre-Admission Screening and Resident Review (PASARR) results for two residents with serious mental illness (SMI). Resident #6 was readmitted to the facility with diagnoses including schizoaffective disorder and bipolar disorder. Her annual MDS assessment incorrectly indicated that she did not meet the state definition of SMI, despite a PASARR Level II Determination Summary Report confirming otherwise. Similarly, Resident #8, who was readmitted with similar diagnoses, had two MDS assessments that inaccurately reflected her PASARR results, both indicating she did not have SMI when the PASARR report stated she did. The MDS Lead confirmed these discrepancies upon review. Additionally, the facility failed to accurately assess the use of insulin for Resident #97. The MDS admission assessment incorrectly documented the use of insulin, despite a review of the resident's physician orders and Medication Administration Record (MAR) showing no evidence of insulin administration. The MDS coordinator acknowledged the error after reviewing the MAR and confirmed that the resident did not receive insulin, indicating the MDS assessment was incorrect.

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